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Applications Will Be Pror-*sed When Submitted Properly Completed. Be Su, To Sign The Application. <br /> APPLICATION <br /> kviRONMENTAL HEALTH PERMIT/SERVYS <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No. <br /> if'>_NSE AND/OR POULTRY RANCHES AND KENNELS <br /> STRATtON MISCELLANEOUS SERVICES Regist. No. <br /> 1. aFR __ Color <br /> [Application Date ��y sq _ Business/Name To Appear On Permit _ 46ej_1 <br /> oType Permit/Service Requested- /�UrG1.(� ._ <br /> i Applicant Name Address_ <br /> d ------.- __ <br /> Business hone No. GIBS E2��-/-/� _ Emergency Telephone No. <br /> -a-Property Location/Address <br /> a Property Owner _.101 [' _ _ - Address �4� � e C� <br /> if <br /> LOperator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees ___ <br /> ALL APPLICANTS: Total Employees Including Operators <br /> 2. ROUSING <br /> ❑ HOTEL/MOTEL/No. of Units ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> .ENNEL/Runways /Animal Population No. No. of Confining Cages_ <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method <br /> Water Supply Source Animal Waste Disposal Method <br /> S. CONSULTATION FEE Fi5W_ "PZdQ,1 r,,e_},6A-y bi ded# AD 5� Le 0.&t <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST Water Well Inspection[] Sample El Title Company <br /> Sewage System Inspection ❑ Address _.__.._ Tele. No. <br /> Escrow No. <br /> Seller . .---- Seller Address <br /> Telephone No. —__— Seller Agent Name .. . . ... _ <br /> Service Request For Date __. ..__... .__._. <br /> I hereby certify that I have prepared this application and that thew will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule n lati of the n Joaqui oval Health District. <br /> r- 7 <br /> APPLICANT'S SIGNATURE X Title cy l Date 41_e7,7 <br /> y <br /> FO EPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SIT ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNTDUE CHECKED <br /> _ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Bo■2009 STOCKTON,CA 85201 <br />